In addition to the tripartite engagement in care, the development of a “third space” shapes the development of the triadic relationship between residents, family and staff in Parkview.
As shown in the findings, throughout the study there were moments of relational care, but often they took place behind closed doors, witnessed by me during my field visits. In my field notes, I wrote:
I was following Helen (the nurse) on her shift and we walked into Lee Ming’s room and discovered Bing (the nursing aide) was reading Lee Ming’s mail to him and to Sum (Lee Ming’s wife). Lee Ming, Sum and Bing were smiling and obviously enjoying a few minutes of connections that went beyond the daily routines. Another nursing aide had come in to ask Lee Ming if he was ready to go for his shower but Lee Ming said that he wanted to wait a bit longer and then Bing laughingly said to all of us “now get out of here so I can finish the mail for Ming and Sum”. It was an occasion when I saw Bing appearing relaxed, not just focused on completing her duties but enjoying the moment with Lee Ming and his wife, Sum. Some staff took great pride in their work, particularly ensuring that residents were “presentable”. I witnessed Helen suggesting to Po Chun how to dress for her cousin’s birthday party, how to wash her newly bought lingerie, and discussing with Man where the discount shop was. There was also a great desire on the part of the staff to just spend time with residents and their families, despite the demands on their time to complete their work assignments. Yet, the reality of the work situation also meant that there were many external factors that inhibited this kind of relational engagement. (field note)
These moments fostered what Bhabha (1990) described as a “third space” in the post- colonial period. Bhabha (1990) introduced the idea of third space to capture a place of cultural hybridity where two forms of culture come together, resulting in the creation of new positions. This third space is interpreted as one where stakeholders from diverse backgrounds can come together to create a new space. It is in this new space that “identities can be recast, negotiated and reorganized, and what becomes the culture is reconstructed in this new space” (Kirkham & Anderson, 2002). Thus I could see a third space emerging in Parkview, places in which residents, families and staff, who come from different social locations and backgrounds, acknowledged but went beyond their differences and created a new pattern of relations care.
In addition, family members also created a “third space” with the residents. For example, as recorded in my field notes:
Man takes Po Chun to the restaurant where the family often went when Man was small to enjoy its signature dish of Swiss chicken wings. Helen confided in Man and Po Chun on one occasion that she also went to this restaurant when she was small. All the stakeholders enjoyed and regained their “lost moment”. (field note)
Staff who participated in this study realised, however, that it was challenging at times to foster the development of a “third space” and to provide care in a way that achieved satisfaction for all. Family members also commented that it was demanding for the staff themselves to meet all of the residents‟ personal needs. As such, an alliance was formed to pursue a set of agreed upon goals – a conscious alliance. In Parkview, making residents feel cared for would seem to be a goal of both families and staff, and this conscious alliance was underscored in the situational reality, for example, by the need to complete large amounts of work in a short time. In this study, I witnessed residents, families and staff negotiating with each other so as to complete the task. For example, Bing (the nursing aide) would negotiate with King whether or not she wanted to have breakfast with its limited choice of food when the staff knew that King would refuse. A conscious alliance was formed between King and Bing so as to complete the task with the least amount of conflict.
In summary, this chapter began with an examination of the empowered citizenship of all stakeholders. Then I discussed the impact of tripartite engagement in care at the interface of hierarchy, power relations and resistance. The third section of the discussion focussed on the “third space” that was formed at Parkview. All of these issues are woven into discourses of ageing and ageism, which foster the socio- political milieu in which they exist. As well, within this socio-political milieu, the historically situated intersections of culture, age, class and group situate individuals in a hierarchical structure that persists through formal and informal processes of interaction. As suggested by Foucauldian epistemology, power was not static; there were acts of resistance in which power relations shifted through negotiation and engagement. These acts provided opportunities to open up and create a new culture, a new shared identity in the “third space” which are ultimately played out in day-to-day interactions between those who live in the facility, visit the residents there and work
at Parkview. As I turn to conclusions and recommendations in the final chapter, I am drawn to the question of what the future holds for Parkview and for the long-term care facility in the broader context.
Chapter Eight
Conclusions and Recommendations
A long-term residential aged care facility is a microcosm of our larger society, albeit intensified, where people from disparate backgrounds come together to live, visit the residents and work. Such a facility is unique in that, unlike a hospital, it is both a site of health care delivery and a place of long-term residence. The facility is often described as a site of difficult relationships for the residents, family members and staff (Hertzberg, Ekman & Axelsson, 2001). Generally, there is a lack of research on the triadic relationship in the long-term residential aged care facility and no research that took into account that each of the stakeholders affects or is affected by the caregiving relationship in the care triad. Previous research has usually been limited to investigate the factors associated with the quality of life and care in such facilities and the experience from a single or two-way perspective of the three main groups: elderly residents (e.g., Gubrium, 1975; Lee, 1997), family caregivers (e.g., Lee, 1999; Nolon & Dellasega, 2000) and health care workers (e.g., Pursey & Luker, 1995), with little consideration given to the care triad as an interactional, multi-stakeholder whole.
Despite the emphasis on the empowered partnering relationships in the long-term residential aged care environment, as enshrinedin the policy paper of the Hong Kong Special Administrative Government called White Paper, Social Welfare into 1990s
and Beyond (1991), partnership is yet to be achieved. It is not surprising then that the
personal knowledge and individual abilities of residents and families as stakeholders often were unrecognised and/or undervalued, and therefore went untapped. The influence and role of each stakeholder has not been adequately studied, and most tragically, minimised. This has further challenged the success of creating triadic relationships in the stakeholder environment and being engaged in care among all stakeholders of the care triad.
The purpose of this study has been to provide empirical data and a theoretical understanding of this care triad in the context of residential care facilities in Hong Kong. The study has described and analysed the pattern and dynamics of the interaction between the elderly residents, their family and the staff with a view to informing professional practice and enhancing quality of care for residents.
The method of inquiry adopted was Charmaz‟s strategy of grounded theory. Throughout the study, I was challenged to observe and listen to the stakeholders in Parkview, which allowed for a constructionist inquiry of the taken-for-granted triadic relationship that exists between residents, family and staff.
The findings from this study have been discussed under three key themes. First, an empowered citizenship emerged in this setting that generated three distinctive care triads, namely the resident-driven triad, the family-driven triad and the staff-driven triad. In the resident-driven triad, the elderly residents expect family and staff to conform to their opinions and ways of doing things. In this type of triad, the residents struggle with their desire to retain acknowledgement of their identity and maintain their own independence in the face of institutional expectations of conformity and their own failing abilities. In the family-driven triad, family members reconstruct their sense of identity as a consequence of role changes and taking on new tasks formerly not performed by them. In the staff-driven triad, the residents‟ individual preferences and needs are subordinated to the rules of the institution. The residents appear to be willing participants, believing that the staff should be in charge and will help them to meet their needs. The residents are obedient and compliant, while the staff member enacts a traditional hierarchical relationship. Second, the impact of a tripartite engagement in care had important consequences for the relationships between residents, family and staff. Third, conscious alliances emerged in the relationship, fostering the development of a “third space” in the dynamic care triad. All of these themes were underscored in the situational reality by external factors, such as medicalisation of care, relations of power and discourses being influenced by the perceived frailty and vulnerability of the elderly, which were ultimately played out in day-to-day interactions between those who live in the facility, visit the residents and work there.
Although sometimes considered as a place where mundane, institutional routines dominate, this study has illustrated that Parkview is a dynamic site of intersecting forces and power relations. The study‟s theoretical perspective provided the opportunity “to move beyond a single axis framework of analysis… to overcome the limitations of the oppressor, in which individuals are characterized monolithically as one or the other” (Alcoff, 1998, p. 484). Unlike previous research in the long-term
care facility, in which solo voices were heard about their experience in the relationship, the triadic relationships found in this study were socially constructed and positioned in the often historically situated intersections of class, the aged, relations of power and examples of resistance and engagement, all reflecting the complex dynamics of bringing together people from different backgrounds to live, visit and work in the same place.